# NTSB WPR11LA318: Piper PA-22-108, N4901Z, Frazier Park, CA, July 8, 2011 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 8, 2011, 13:15 local (20:15 UTC) - Place: Frazier Park, CA - Coordinates: 34.737777, -119.251388 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.7378&lon=-119.2514&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report May 21, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 81050 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR11LA318 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81050/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81050 - Page: https://openairdocs.org/ntsb/WPR11LA318 ## Probable cause The pilot’s geographic disorientation, which resulted in an off-airport precautionary landing in soft terrain and a subsequent nose over. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of charts](https://openairdocs.org/ntsb-findings/02063025): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-22-108, 1 case](https://openairdocs.org/ntsb-findings/02063025/cases.md?model=7102204), [All aircraft, 10 cases](https://openairdocs.org/ntsb-findings/02063025/cases.md) - [Perception/orientation/illusion: geographic disorient (lost)](https://openairdocs.org/ntsb-findings/02022030): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-22-108, 1 case](https://openairdocs.org/ntsb-findings/02022030/cases.md?model=7102204), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/02022030/cases.md) - [Runway/land/takeoff/taxi surface: soft surface](https://openairdocs.org/ntsb-findings/03023020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-22-108, 2 cases](https://openairdocs.org/ntsb-findings/03023020/cases.md?model=7102204), [All aircraft, 264 cases](https://openairdocs.org/ntsb-findings/03023020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-22-108, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102204), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [Piper PA-22-108, 8 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=7102204), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot reported that, during the flight, he was following an interstate highway and that he then turned west to intercept a state highway and head toward his destination. He was flying about 1,000 feet above mountainous terrain when he became lost and disoriented while trying to navigate using maps and GPS. He then thought that the airplane was losing altitude. Subsequently, he concentrated on the terrain rather than direction, decided to make an off-airport landing, and landed the airplane in a dry river bottom. During the landing roll, the nosewheel dug into soft dirt, and the airplane nosed over. Postaccident engine and airframe examinations revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. ## Factual narrative On July 8, 2011, about 1315 Pacific daylight time, a Piper PA-22-108, N4901Z, nosed over during an off airport precautionary landing near Frazier Park, California. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot and one passenger were not injured; the airplane sustained substantial damage from impact forces. The personal cross-country flight departed Los Banos, California, about 1030, with a planned destination of Lompoc, California. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot stated that he had been following Interstate 5, and then turned to the west to intercept Highway 166 to Santa Maria, California. He thought that the airplane was losing lift, and decided to land in a dry river bottom. During the landing roll, the nose wheel dug into soft dirt, and the airplane nosed over. In a subsequent statement, the pilot stated that he was flying about 1,000 feet above the mountainous terrain. He thought that the engine was running fine, but not producing the power needed for the airplane to maintain altitude. He concentrated on the terrain rather than direction. The mixture was in the full rich position; he did not lean it, and did not recall using carburetor heat. He decided to make an off airport landing. The pilot circled a road, but was not comfortable with landing on it, and decided to land in a dry river bottom next to the road. The Ventura County Sheriff responded to the accident site. The pilot told the responding deputy that he became lost and disoriented over Lockwood Valley using maps and a global positioning satellite system (GPS) to navigate. The pilot stated that the engine began to fail, and he attempted to make an emergency landing when the engine finally quit. The pilot attempted to land on Lockwood Valley road, but was unable to do so and he landed in the river bed. Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on July 11, 2011. Detailed examination notes are part of the public docket. Postaccident examination of the engine and airframe revealed no evidence of preimpact mechanical malfunction for failure that would have precluded normal operation. ## Aircraft - Registration: [N4901Z](https://openairdocs.org/aircraft/N4901Z), registered now, S/N 22-8486 (OpenAirDocs) - Reported make and model: PIPER PA-22-108 - Registry model: [Piper PA-22-108](https://openairdocs.org/model/piper-pa-22-108) (registry code 7102204) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 22-8486 - Airframe hours: 5325 - Engines: LYCOMING O-235-C1B 115 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: John Thomason - Registered owner: John Thomason - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 9, 2011 - Departed: LSN, Los Banos, CA - Destination: LPS, Lompoc, CA - Equipment: Stall warning system, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 77; injuries: none; private; airplane ratings: single-engine land, single-engine sea, multi-engine land; medical: class 3, with waivers/limitations; last flight review June 3, 2011; seat: left; flight hours: 1,300 total, 150 in this make and model, 1,300 as pilot in command, 10 in the last 90 days, 5 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 61 °F - Altimeter: 29.86 inHg - Observed at: KSBA ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20110708016679A](https://openairdocs.org/incident/20110708016679A), Jul 8, 2011: Piper PA-22-108, Frazer Park, CA, Minor damage. On 07/08/2011, N4901Z collided with the ground while trying to out climb ascending terrain in a canyon. The pilot stated that he had become lost while using a… ## Other investigations on N4901Z (2) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB OAK68D0314](https://openairdocs.org/ntsb/OAK68D0314), Dec 21, 1967: Piper PA-22 (N4901Z), Travis Afb, CA, substantial damage - [NTSB OAK66F0181](https://openairdocs.org/ntsb/OAK66F0181), Dec 18, 1965: Piper PA22 (N4901Z), Lincoln, CA, substantial damage ## Docket (3 files) The files NTSB released with the investigation on April 7, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81050. 2.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409252&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 2, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409255&FileExtension=.PDF&FileName=Pilot%20Statement-Redacted.PDF - NTSB Engine Exam Notes (item 3, .PDF, 433 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409256&FileExtension=.PDF&FileName=NTSB%20Engine%20Exam%20Notes-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.